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What is body dysmorphic disorder

Many of us have some degree of dissatisfaction with our body. A survey of over 4000 people, in the magazine Psychology Today, for example, found that 56 per cent of women reported being dissatisfi ed with their appearance. Major sources of dissatisfaction were the abdomen (71 per cent), body weight (66 per cent), hips (60 per cent), and muscle tone (58 per cent). Major concerns for men were their abdomen (63 per cent), weight (52 per cent), muscle tone (45 per cent) and chest size (38 per cent). Signifi cantly less of us are so unhappy that this dissatisfaction reaches pathological proportions. Bohne et al. (2002), for example, found that while 74 per cent of American university students had body image concerns, only 29 per cent were preoccupied by them, and only 4 per cent met DSM-IV criteria for body dysmorphic disorder. Among the general population, prevalence rates are about 2.5 per cent in women and 2.2 per cent in men (Koran et al. 2008). Not surprisingly, perhaps, rates are higher among people seeking plastic surgery, where they are around 10 per cent (Aouizerate et al. 2003). Sadly for these people, surgery rarely improves their feelings about themselves. Body dysmorphicdisorder – sometimes referred to as dysmorphophobia – involves a preoccupation with an imagined defect in appearance. In addition, people with the disorder experience signifi cant levels of negative thinking, self-criticism, anxiety and depression. DSM-IV-TR stated the following criteria must be met for its diagnosis:

Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

The preoccupation causes clinically signifi cant distress or impairment in social, occupational or other areas of functioning.

Concerns can involve preoccupations with the face (such as scars, spots, acne, or the shape or size of the nose, mouth, etc.), the hair (fears of receding hairlines), or the size and shape of any other body part, including hips, buttocks, legs and hands. Men tend to be concerned about their body build, genitals and hair. Women focus on their hips, breasts and legs (Phillips et al.2006a). Typical behaviours include:

frequent checking of appearance in mirrors

camouflaging the perceived defect with clothing, make-up or posture

seeking surgery or other medical treatment

attempts to convince other people of the deformity

skin picking

measuring the disliked body part

excessive dieting or exercise

avoiding social situations in which the perceived defect may be exposed

feeling very anxious and self-conscious around other people because of the perceived defect.

Levels of distress can be such that many people with body dysmorphic disorder experience major depression, social phobia, and substance abuse (Sobanski and Schmidt 2000). Up to 80 per cent experience suicidal ideation at some time in their life, and around a quarter will attempt suicide (Phillips 2006). Less dramatically, the condition may prevent normal social, economic and sexual relationships. Didie et al. (2008), for example, found that 80 per cent of their sample of people with body dysmorphic disorder reported some degree of impairment in work: 39 per cent claimed not to have worked in the previous month as a result of their disorder. About 10 per cent of people with the disorder will also be given a diagnosis of anorexia (Philips1996a). Rates of spontaneous remission are low (Phillips et al. 2008). A number of clinicians have considered whether body dysmorphic disorder is signifi cantly different to other diagnoses, and whether it can be subsumed within them.

The American Psychiatric Association (2000) suggested that some people may believe so strongly that they have a physical deformity that their beliefs may be considered delusional, and the disorder be considered a psychotic disorder. By contrast, Phillips et al. (2006) adopted a dimensional view, arguing that people with extremely strong beliefs are no different from people with a ‘non-delusional’ disorder, except in the strength of their belief – and should therefore not be considered under a separate diagnosis.

A second suggestion is that body dysmorphic disorder may be considered a variant of obsessive-compulsive disorder. The preoccupations held by people with body dysmorphic disorder resemble obsessions, in that they are anxiety-producing, recurrent and diffi cult to control. Repeated checking or other procedures to reduce anxiety are also similar to obsessive-compulsive disorder. In addition, both psychological (exposure plus response prevention) and pharmacological (SSRI) treatments used to treat obsessive-compulsive disorder have also proven effective in treating body dysmorphic disorder. Finally, family members with body dysmorphic disorder are more likely to have a relative with obsessive-compulsive disorder than the general population. Despite these similarities, a number of important differences have been found between the two disorders. Compared to people with obsessive-compulsive disorder, those with body dysmorphic disorder experience poorer insight, higher co-morbidity with major depression, social phobia and psychotic disorders, and higher suicide attempt rates.

A third approach has argued that body dysmorphic disorder is a form of eating disorder – or that body dysmorphic disorder and eating disorders lie on a continuum of disorders relating to body image distortion. Cororve and Gleaves (2001) identifi ed the key driver of both body dysmorphic disorder and eating disorders as excessive concerns about physical appearance. Perhaps the most problematic issue for this model is that it assumes eating disorders are primarily driven by weight or appearance concerns. While this is generally true of bulimia, these may form only part of the clinical picture in anorexia.